Individual
GROVER CLEVELAND JOHNSON IV
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3600 COUNTRY CLUB DR STE 530A, JEFFERSON CITY, MO 65109-1060
(573) 606-7100
Mailing address
7530 ENON RD, RUSSELLVILLE, MO 65074-2602
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2018037368
MO
Other
Enumeration date
04/05/2022
Last updated
04/05/2022
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